Treatment Concerns - Definitions / Living Wills / Palliative Care / Terminal or Excessive Sedation / Organ Donation / DCD or NHBD / Hospice / POLST / DNR

Donor: Before or After Death?

Excerpt from “Death and the Organ Donor”

[Comment: Truog, et al. have been advocating organ harvesting before death for many years. Non-heartbeating organ donation (now called DCD here) has been going on since the early 1990s and I’ve been writing about this unethical practice since the late 1990s (see excerpt from my 2009 article “Death and the Organ Donor” below) but the whole issue has received little media attention.
Now it seems that the “bioexperts” are finally ready to go public. As usual, this controversial issue is portrayed as “just” taking the kidneys with the excuse that this is harmless to the person. Really??
But look at the comments! Almost all the current ones are against this. Even without knowing all the facts about DCD, it seems most people have basic common sense. N. Valko RN]

Excerpt from “Death and the Organ Donor”, online at :

“The Council’s (the President’s Council on Bioethics) white paper admitted that the legal definition of irreversible cessation of heartbeat and breathing used to justify DCD/NHBD has problems. Most people would consider “irreversible” in this context to mean that the heart has lost the ability to beat. But in DCD/NHBD, “irreversible” instead means that there is a deliberate decision not to try to restart the heart when it stops and that enough time has elapsed to ensure that the heart will not resume beating on its own. However the Council had to admit the dearth of scientific evidence supporting this determination. In some cases involving babies, for instance, the heart is harvested and actually restarted in another baby.

“The Council also admitted that even fully conscious but spinal-cord-injured patients have become DCD/NHBD donors when dependent on a ventilator. This sad fact is the result of virtually all withdrawal-of-treatment decisions now being considered legal and thus ethical.

“The Council also noted that even though doctors are advised to take their time determining death when a natural death occurs, the interval between declaring death and starting transplantation in a DCD/NHBD patient has been as short as 75 seconds. It seems obvious that the push for a speedy declaration of death is not about new scientific information determining the moment of death but rather a desire to quickly get organs because “[t]he longer a patient removed from ventilation ‘lingers’ before expiring, the more likely are the organs destined for transplantation to be damaged by warm ischemia [lack of adequate blood flow]”.5 But even while expressing concerns, the Council still supported the DCD/NHBD concept in the end.

“Despite pages discussing these DCD/NHBD issues, the Council unfortunately ignored a most crucial issue: How do doctors determine who is a “hopeless enough” patient with functioning vital organs and who will also die fast enough to get usable organs?

“The Council never mentioned articles like the one in the September/October 2008 issue of the Journal of Intensive Care Medicine, which stated “Donation failure [patients who don’t die fast enough to have usable organs] has been reported in at least 20% of patients enrolled in DCD”. Those authors also concluded that “There is little evidence to support that the DCD practice complies with the dead donor rule”.6”–abc-news-health.html
Remove Kidneys for Transplant Before Donor’s DeathBy KIM CAROLLO | Good Morning America – 21 hours ago
The severe shortage of viable organs for transplantation in the U.S. has led a transplant surgeon to propose harvesting kidneys from people who are not dead yet.

Dr. Paul Morrissey, an associate professor of surgery at Brown University’s Alpert Medical School, wrote in The American Journal of Bioethics that the protocol known as donation after cardiac death — meaning death as a result of irreversible damage to the cardiovascular system — has increased the number of organs available for transplant, but has a number of limitations, including the need to wait until the heart stops.

Because of the waiting time, Morrissey said that about one-third of potential donors end up not being able to donate, and many organs turn out to not be viable as a result.

Instead, he argues in favor of procuring kidneys from patients with severe irreversible brain injury whose families consent to kidney removal before their cardiac and respiratory systems stop functioning.

“These individuals, maintained on mechanical ventilation, do not meet the criteria for brain death,” he wrote. In these cases, the patient would be removed from life support and kidneys would be harvested while ensuring that the patient receives anesthesia and pain relief during the operation. After that, the patients would be kept comfortable until they have not had a pulse for five minutes, a threshold at which they are declared dead.

“Under this protocol, the donor is alive at the time of kidney recovery, but a determination has been made and confirmed by medical experts that death is imminent,” he wrote.

Kidney removal, he stressed, would not cause the death of the donor, which is “instead caused foremost by the original catastrophic injury and secondarily by terminating mechanical ventilation.”

In addition to providing more organs usable for transplant, Morrissey said this revised protocol would allow families to grieve in peace, since surgeons wouldn’t need to rush the body into the operating room to remove organs. He said they could also take comfort in the knowledge that their loved one’s death saved other lives.

A number of experts responded to Morrissey’s proposal in commentaries published in the same journal. Some supported his arguments, while others expressed concern that it wouldn’t be in the donor’s best interests and could potentially violate medical ethics and the law.

Donald Marquis, a professor at the University of Kansas, wrote that Morrissey’s argument has some validity.

Removing both kidneys, he said, “will not make the donor worse off than the donor would have been in the absence of the nephrectomy.”

“Though not dead yet, they are ‘as good as dead’ from an ethical perspective,” wrote Franklin Miller, a bioethicist at the National Institutes of Health, along with Dr. Robert Truog, a professor of medical ethics, anesthesiology and pediatrics at Harvard Medical School. “No harm or wrong is committed by procuring vital organs prior to stopping life support, provided that valid consent is obtained for donation.”

But removing both kidneys from a living donor would not always be in a patient’s best interests.

“There is no reason to believe that registering as an organ donor involves the willingness to undergo premortem double nephrectomy,” argued bioethicists Maxwell Smith of the University of Toronto, David Rodriguez-Arias of the Spanish National Research Council and Ivan Ortega of Alcala de Henares University.

And Norman Cantor, a distinguished professor of law at Rutgers School of Law, wrote that removing both kidneys before death could be legally risky.

“An organ retrieval intervention poses some hazard of accelerating death, as by hemorrhage or cardiac arrest,” he said. “Any medical action potentially accelerating death, even by a few minutes and even for a gravely debilitated patient, demands a legally recognized justification.”

Removing one kidney, he said, could be legally defensible, but removing both “would almost certainly be deemed unlawful under the current legal framework.”
N Valko RN